The National Eating Disorder Association (NEDA) defines eating disorders as “serious but treatable mental and physical illnesses that can affect people of all genders, ages, races, religions, ethnicities, sexual orientations, body shapes, and weights.” Though the reported statistics on eating disorders and eating disorder diagnosis vary, it is estimated that over 28 million Americans will have an eating disorder in their lifetime [1].
Of these approximately 28 million Americans, anorexia nervosa, bulimia nervosa, binge-eating disorder, and other specified feeding or eating disorders (OSFED) are the most commonly diagnosed [1]. According to the Office on Women’s Health, “Compared to men, women are up to five times more likely to be diagnosed [with an eating disorder]…” with OSFED as the the most commonly diagnosed eating disorder of the diagnoses.
Eating disorders are complex and impact every aspect of a person’s health and wellness. The adverse physical consequences of [unhealthy] dieting, [unhealthy] weight loss and purging behaviors are notable and sometimes fatal [1].
Eating disorders are complex and impact every aspect of a person’s health and wellness. The adverse physical consequences of [unhealthy] dieting, [unhealthy] weight loss and purging behaviors are notable and sometimes fatal.
Fortunately, for women, changes in our reproductive health (and overall health) can be observed in our hormonal biomarkers, which are observable signs of fertility that change in response to what is going on in our bodies. Since eating disorders not only change eating behaviors but impact physical activity, hydration, emotional wellbeing, social networks, and substance use or abuse, it is important for women to increase their body literacy, improving their understanding of healthy hormonal interplay and how certain behaviors impact reproductive health.
Understanding the menstrual cycle
Many women are surprised to learn that the main event of a woman’s menstrual cycle is ovulation—not menstruation.
Ovulation occurs when hormones from the brain signal the ovaries to develop a handful of follicles (egg cases). Eventually, one follicle will become dominant, producing estrogen. When estrogen levels peak, the brain triggers the release of luteinizing hormone (LH), which leads to the release of the dominant follicle’s egg. After the egg is released from the ovary (i.e., the event of ovulation) then the ruptured follicle starts to produce the hormone progesterone.
This hormonal interplay takes place over 24-36 days in a healthy ovulatory cycle. And even though we only mentioned estrogen, LH, and progesterone above, over a dozen hormones rise and fall over the course of a healthy cycle to make ovulation happen. Kind of like dominoes, each hormone must reach a specific level to trigger the release of the next hormone. Successful ovulation declares that the necessary hormonal communication occurred to trigger the event of ovulation.
Energy availability for a healthy menstrual cycle
In order for all of this necessary hormonal communication to take place, a woman’s body must be capable of triggering these hormonal events. As you might imagine, a good deal of energy is needed for this important physiological activity.
A 2021 publication acknowledges that we have known for many years that metabolic and nutritional status affects reproductive function; however, it wasn’t until the 1970s that a deeper understanding of that hormonal interplay became known and it was not until the mid 1980s that the concept of “brain energy availability” was proposed [2].
Energy availability is required for hormonal communication
The concept of brain energy availability suggests that the brain seems to “monitor the balance between the availability of calories (energy) and their utilization [2].” As a result, reproductive function (i.e., ovulation) can be temporarily suppressed when the balance of available energy is not ideal.
The concept of brain energy availability suggests that the brain seems to “monitor the balance between the availability of calories (energy) and their utilization.” As a result, reproductive function (i.e., ovulation) can be temporarily suppressed when the balance of available energy is not ideal.
Since the 1980s, studies have continued on energy availability and utilization. Research has uncovered that negative energy status or a disrupted energy utilization can cause a decrease in kisspeptin activity—and kisspeptin helps control the release of GnRH (gonadotropin-releasing hormone) from the brain [2,3,4]. Kisspeptin also tells the pituitary gland (brain) to release two key hormones that kick-start the maturation of an egg in a follicle.
Insufficient levels of kisspeptin will not trigger a sufficient release of GnRH, which will result in irregular menstruation (via delayed or suppressed ovulation). In short, the domino effect does not happen—and neither does ovulation.
Eating disorders can cause negative energy availability or disrupted energy utilization
If the body’s balance of available energy is off (as can quickly become the case with eating disorders) then reproductive function is not prioritized by the body, which senses it is not a safe time for a possible pregnancy. Delayed or suppressed ovulation can happen for a variety of reasons, one of which is an eating disorder’s effect on hormonal communication. In fact, with both undernutrition (negative energy) and overnutrition (disrupted energy utilization)—both of which are possible for women living with an eating disorder—it seems kisspeptin activity decreases.
And it’s not just eating disorders that can cause negative energy availability or disrupted energy utilization. Weight loss due to calorie restriction, excessive exercise, and conditions like obesity and diabetes can all impact ovulation and the menstrual cycle [2,3,4].
Losing your period isn’t “normal” or “healthy”
While missing ovulation isn’t obvious (unless you’re tracking your cycles closely!) “losing” your period is—and it’s often one of the first signs of an energy imbalance. For some women, the loss of one’s period might seem like a bonus. But a missing period is actually a huge red flag that your body does not feel safe enough to ovulate. In other words, a missing period is the body’s way of telling a woman she doesn’t have enough energy for procreation, and is in “survival mode,” trying to conserve energy rather than put it towards ovulation and the potential for pregnancy.
But a missing period is actually a huge red flag that your body does not feel safe enough to ovulate. In other words, a missing period is the body’s way of telling a woman she doesn’t have enough energy for procreation, and is in “survival mode,” trying to conserve energy rather than put it towards ovulation and the potential for pregnancy.
When a woman loses her period (or experiences irregular periods) due to an eating disorder, the return to fertility (via healthy, regular ovulatory menstrual cycles) is part of the longer journey of eating disorder recovery.
A return to fertility during eating disorder recovery
As a woman recovering from an eating disorder moves towards improved physical health, she may experience a “mini-puberty” of sorts, as her body moves (more swiftly) through many cycle types similar to her initial puberty (short luteal phases, light bleeds, etc., moving towards increasingly healthier biomarker observations in subsequent cycles). Alternatively, she may return to fertility without any “mini-puberty” experiences. Similar to the postpartum return to fertility experience, no two women recovering from an eating disorder will return to fertility in the same way.
Similar to the postpartum return to fertility experience, no two women recovering from an eating disorder will return to fertility in the same way.
Unlike women who have not experienced eating disorders, those battling or recovering from an eating disorder may need to work through eating disorder specific recovery needs resulting in other physical health consequences in the cardiovascular system, gastrointestinal system, neurological system, and/ or endocrine system.
Encouragingly, in doing the work of eating disorder recovery (relapses and all), women do tend to experience a return to fertility. A 2020 publication titled “Fertility and Reproduction after Recovery from Anorexia Nervosa” noted, “recovered female patients do not seem to differ in most aspects from matched healthy controls with respect to pregnancies and the development of their offspring [5].”
Recovery takes time, but it’s worth it—and so are you
Full recovery from an eating disorder can take a long time, and it requires support from professionals, friends, and family. Once a woman finds the right treatment team, the recovery work is grueling and emotional, but absolutely crucial to pursuing a healthier body and mind.
All of this is to say, the timeline for eating disorder recovery is unique to the individual. But with the right support, healing is possible. And while the psychological and behavioral healing from an eating disorder is critical to full recovery, the outward signs of recovery, like weight restoration, nutritional rehabilitation, and a return to fertility (ovulation!) are also important milestones in a longer journey of holistic recovery.
Resources for eating disorder recovery support:
- https://www.nationaleatingdisorders.org/find-treatment/
- https://www.allianceforeatingdisorders.com/find-treatment/
